Health Information Technology and Health Information Exchange Implementation inRural and Underserved Areas:

Findings from the AHRQHealth IT Portfolio

Agency for Healthcare Research and QualityAdvancing Excellence in Health Care www.ahrq.gov Health IT

Health Information Technology and Health Information Exchange Implementation inRural and Underserved Areas:Findings from the AHRQ Health IT Portfolio

Prepared for:Agency for Healthcare Research and QualityU.S. Department of Health and Human Services540 Gaither RoadRockville, MD 20850www.ahrq.gov

Prepared by:Julie M. Hook, M.A., M.P.H., John Snow, Inc.Erin Grant, Booz Allen HamiltonAnita Samarth, ASTECH Consulting

AHRQ Publication No. 10-0047-EFFebruary 2010

Suggested Citation:

Hook JM, Grant E, Samarth A. Health Information Technology and Health

Information Exchange Implementation in Rural and Underserved Areas: Findings

from the AHRQ Health IT Portfolio. AHRQ Publication No. 10-0047-EF.

Rockville MD: Agency for Healthcare Research and Quality. February 2010.

The authors of this report are responsible for its content. Statements in the report

should not be construed as endorsement by the Agency for Healthcare Research

and Quality or the U.S. Department of Health and Human Services.

Introduction........................................................................................................................................1

Background ....................................................................................................................................1

Rural and Underserved Communities ........................................................................................1

Benefits of Health IT and HIE ...................................................................................................2

Barriers of Health IT and HIE ..................................................................................................2

Method and Approach .................................................................................................................4

Findings................................................................................................................................................6

Technical..........................................................................................................................................6

Connectivity..................................................................................................................................6

Vendor Solutions and Capabilities..............................................................................................7

Policy and Procedures ..................................................................................................................8

Privacy and Confidentiality ...........................................................................................8

Information Exchange Standards ...................................................................................9

Organizational .............................................................................................................................10

Insufficient Informatics Expertise .................................................................................10

Staff for Planning and Implementation ........................................................................11

Lack of Basic Computer Literacy .................................................................................11

Training .....................................................................................................................12

Organizational Leadership ..........................................................................................12

Staff and Physician Buy In ..........................................................................................13

Financial........................................................................................................................................14

Funding .....................................................................................................................14

Conclusion ........................................................................................................................................16

References ..........................................................................................................................................18

Appendix............................................................................................................................................22

Contents

1

In 2004 and 2005, the Agency for Healthcare Research and Quality (AHRQ) awarded $139

million in funding for health information technology (health IT) and health information

exchange (HIE) projects.1 The AHRQ health IT portfolio consists of grants and contracts to

support organizational and community-wide implementation and diffusion of health IT and

to assess the extent to which health IT contributes to measurable and sustainable

improvements in patient safety, cost, and overall quality of care. As part of this funding,

AHRQ awarded 40 implementation grants under the Transforming Healthcare Quality

through Information Technology (THQIT) grant program. These grants focused on

improving care in rural and underserved areas and a significant portion of grantees

concentrated their health IT funding to organizations providing care to these populations.

The AHRQ Health IT portfolio also includes a National Resource Center for Health IT

(NRC), created to support the many projects funded by AHRQ and the Nation in adopting

and evaluating health IT. The NRC has established an infrastructure for collecting, analyzing,

and disseminating best practices and lessons learned from AHRQ’s portfolio of health IT

projects. This report focuses on the challenges facing rural and underserved communities in

integrating health IT into their health care delivery systems.

The NRC Technical Assistance (TA) team developed this report to disseminate findings,

solutions, and lessons learned on the potential barriers and challenges to implementing

health IT and HIE applications to providers serving rural and underserved communities in

the AHRQ Health IT TQHIT program. It is hoped that by disseminating these lessons

learned, those who are new to the field will be able to avoid some of the pitfalls and build on

the success stories.

Background

During an initial literature review, the NRC TA team found that many of the health concerns

and access to care issues of rural communities are similar to those of other underserved

communities. In addition, the literature review revealed that health IT adoption barriers and

challenges of the health care organizations that serve rural and underserved populations are

Introduction

2

also similar. Therefore, the approach for this project was to include grantees serving rural or

underserved communities in a single findings report.

Rural and Underserved Communities

While there are many different definitions of rural communities, here we define rural

populations as those residing within a county or area not designated by the Office of

Management and Budget as a Metropolitan Statistical Area (MSA), which has at least one

city with 50,000 or more inhabitants and a total population of at least 100,000.2 Similarly,

there is no single, accepted definition of an underserved population. Here, we define

underserved populations as groups whose demographic, geographic, or economic

characteristics impede or prevent their access to health care services,3 such as low-income

individuals, the uninsured, immigrants, racial and ethnic minorities, and the elderly.

There are significant health disparities and access to care issues that are specific to rural and

underserved populations. Rural and urban areas differ in many ways, including demography,

environment, economy, social structure, and availability of resources.4 Compared to other

geographic areas, rural residents are more likely to be elderly, poor, in fair or poor health,

and to have higher rates of chronic disease and poor health behaviors. In addition, they are

less likely to receive recommended preventive services and report, on average, fewer visits to

health care providers.4-7

It is well known that the underserved, including low-income individuals, minorities, and the

uninsured, are more likely to be in fair or poor health and to suffer from chronic diseases

such as hypertension, asthma, and diabetes; have less access to health insurance; and are less

likely to have a primary care provider and rely on the emergency department for their usual

source of care.5,8,9

Access to care is an issue in regions where physician-to-patient ratios are inadequate, or

where there are not enough medical specialists available to meet the population’s needs.

Rural areas struggle to maintain adequate numbers of clinical staff to serve their patient

populations. While 20 percent of the U.S. population resides in rural areas, approximately

9 percent of physicians and 10 percent of specialists practice there.10 Lack of access to

3

medical specialists is not just a rural problem. Many urban, underserved settings also do not

have enough specialists to provide care in fields such as dermatology and stroke care.11,12

Access to a regular source of care and specialty care can have a negative impact on health

outcomes. When patients are better able to access medical care, they can have acute

conditions treated locally, receive treatment for medical problems before they become

critical, and receive care to better manage chronic conditions.13,14 Clinical evidence indicates

that access to appropriate care can improve the health status of patients with chronic

diseases and thus reduce or eliminate health disparities.15

Benefits of Health IT and HIE

Health information technologies, such as electronic health records (EHRs), computerized

provider order entry, clinical decision support, electronic prescribing, telehealth, and other

technologies that enable HIE have been promoted as potential tools for improving the

quality, cost, and efficiency of the U.S. health care system. A growing body of research

demonstrates that health IT and HIE can improve medication safety, chronic care

management, and compliance with treatment guidelines, as well as improve the efficiency of

hospital workflow and reduce the cost of care.16-26

Despite the growing literature on general use of health IT, the majority of this information

has focused on data from urban or suburban centers or academic medical centers; little is

known about the benefit of health IT in rural and underserved settings.27 However, the

ability for health information to be exchanged between organizations may be more

important for providers that care for underserved populations because these patients are

more transient, less likely to have a primary care provider, and seek care from a variety of

organizations (e.g., emergency department or county health department). Because patients

seeking care from safety net providers often have more complex physical and mental health

needs, health IT offers substantial potential benefit. Disease registries and decision support

can help providers manage their complex chronic care needs, and HIE capabilities can allow

providers to coordinate and manage patient care more effectively between multiple sites of

care. Research has demonstrated that where access to medical specialties is scarce, telehealth

technologies can improve access to specialty care in underserved urban and rural areas and

among underserved populations who are institutionalized, such as inmates and nursing home

residents.11, 28-30

4

Barriers of Health IT and HIE

Despite these potential benefits, it is estimated that only 8 to 12 percent of hospitals and 4

percent of ambulatory care providers in the United States have adopted comprehensive

EHRs.31, 32 The reasons for the relatively slow rate of adoption of technology in the overall

health care field are increasingly well understood and include high capital and maintenance

costs; lack of a sustainable business model; security or confidentiality issues; not finding a

system that meets practice or department needs; end-user acceptance; absence of common

data standards; lack of leadership or a strategic plan; concern that the system will become

obsolete; and lack of available staff with adequate expertise in IT.31-34 The success of HIE

initiatives depends on the ability to address several complex and interdependent problems

concurrently, including establishing interoperability, building public trust, assuring

stakeholder cooperation, and developing financial sustainability,35-39 all of which can

contribute to slow adoption or even derail projects.

These issues are not unique to the organizations serving rural and underserved populations,

but are exacerbated in these settings due to their lack of financial, personnel, and other

resources. Barriers identified as unique to the health care organizations serving rural and

underserved populations include products that are not applicable to community health

centers (CHCs) or federally qualified health centers (FQHCs) who have unique reporting

requirements, problems with reimbursement, and a focus on technology issues at the

expense of health and business issues.40,41

Method and Approach

In July 2008, the NRC TA Team hosted an open forum with THQIT grantees that

implemented technology in either a rural or underserved area. The NRC routinely conducts

open forums with grantees to provide a venue for grantees to share experiences, challenges,

and lessons learned with each other on a particular topic of interest. The grantees were

invited to this open forum based on whether they self-identified as working with rural

populations, safety net organizations, FQHCs, and organizations serving medically

underserved areas or populations, including the elderly, uninsured, underinsured, Medicaid

recipients, and other low-income groups.

5

A total of 13 grantees and members of their team participated in the voluntary open forum,

as well as followup discussions, during routine technical assistance phone calls, during which

grantees described their experiences implementing health IT in rural and undeserved areas.

The open forum included a discussion of implementation challenges in the areas of

interoperability, provider adoption, reporting/patient data management, resources, and

vendor solutions. The group also discussed critical success factors for collaborative

partnerships, financial support, IT capacity, organization size, provider adoption, and

stakeholder support. The grantees represent geographically diverse areas in the United States,

serving a wide range of populations in both rural and urban settings. While the technologies

being implemented varied among grantees, the majority of grantee goals included improving

access to care and some element of HIE between health care providers or organizations.

More detail on each of the participants’ projects is outlined in the Appendix.

The results of the open forum and followup calls were captured and summarized to identify

themes and key points discussed. The purpose of this document is to highlight the

challenges identified by the grantees along with their real-world solutions. This document is

not meant to be a comprehensive overview of all health IT and HIE implementation

challenges facing rural and underserved areas but highlights some key areas that are either

unique or recognized as having a higher impact among these organizations.

6

The NRC TA Team identified four major themes from the open forum: technical, policy and

procedures, organizational, and financial. Each is discussed in more detail below.

Technical

Connectivity

While the majority of Americans have access to adequate Internet connectivity,42 broadband

connectivity, the ability to quickly and reliably access the Internet by fixed and mobile

communications devices, is still an issue for many of the rural grantees. The ability for them

to utilize their health IT hinged on connectivity: temporary disruptions to productivity or

disruptions in access to records when Internet connectivity was down or slow was cited as a

huge challenge. These rural grantees cited events that would not be as common in urban

areas such as hunters shooting down lines. However, because of this, the grantees noted that

they felt like they are prepared and developed procedures and contingency plans for what to

do when connectivity was down.

Because of the connectivity issue, some project teams were against using an application

service model (ASP) for EHRs. While ASP EHR models are generally less expensive than

local installations, since a server is not required at every individual practice location, the

potential for Internet disruption could greatly disrupt information exchange and thus patient

care. One grantee noted that they decided to implement the more expensive local

installations for their providers because of this concern from their providers.

The Federal Government has taken steps to address Internet connectivity in the American

Recovery and Reinvestment Act of 2009 (ARRA), which includes provisions aimed at

increasing broadband service in underserved areas. Within the ARRA is the establishment of

a “national broadband service development and expansion program,” by the U.S.

Department of Commerce in consultation with the Federal Communications Commission.

The National Telecommunications and Information Agency was allocated $4.7 billion to be

distributed as grants for a wide variety of purposes including: equipment purchases;

Findings

7

construction and deployment of broadband service related infrastructure; and facilitating

access to low-income, unemployed, aged and other vulnerable populations.

Vendor Solutions and Capabilities

A major barrier cited by the majority of the grantees was that vendors did not have products

that would adequately meet their needs. There was a discrepancy between the presentations

organizations received from vendors and their actual ability to do what they promised. While

the grantees acknowledged that vendors would never have a turn key product and that all

technology implementations would require some level of customization, vendor products

were not geared to their organizations. For example, one grantee remarked on the lack of

experience of vendors working with the Indian Health Service Resource and Patient

Management System (RPMS), while another described the difficulty in implementing

software developed for the private-sector health maintenance organization (HMO)

environment into a safety-net hospital due to the difference in Medicaid and HMO claims

information.

Safety net organizations often need more vendor product customization and specialized

support because of their patient populations, which require more complex and wide-ranging

services; that care entails more complex billing and unique reporting. For example, CHCs

funded through the Health Resources and Services Administration’s (HRSA’s) Health Center

Program are required to submit the uniform data system (UDS) report annually; centers

funded to provide HIV-AIDS services are required to report data for the Ryan White

Services Report. Safety net providers are often funded from a variety of sources and thus

required to generate separate reports to those funders regularly. Safety net and CHCs rely on

their health IT systems to provide necessary information for reporting, but vendors are often

not familiar with these specialized needs and the products often do not allow for this kind of

reporting. Grantees discussed that vendors struggled to use software developed for the

private environment and apply it to the safety net environment because of their unique

reporting requirements and services. Some grantees reported that vendors were opposed to

creating or developing solutions or interfaces for their environment or charged fees that were

prohibitive for them.

8

While not unique to organizations serving rural and underserved communities, many

grantees noted their frustration with vendors verbally committing to capabilities and support

of these unique groups, and then ultimately not being able to deliver the desired

functionality or increasing the price to do so. This underscores the importance of selecting a

vendor with a satisfied customer base that includes organizations similar to the organization

purchasing the system and developing well-defined contracts.

Policy and Procedures

The grantees cited that the most critical issues influencing health IT and HIE development

and implementation are developing security and confidentiality policies and creating

standards, which mirrors issues cited in the literature.43

Privacy and Confidentiality

While addressing privacy and security of personal health information (PHI) is critical for all

organizations, it is an even greater concern for rural areas where most of the staff and

patients know each other. It is also a concern in urban areas, where safety net clinics often

make an effort to hire members of the community they serve. The grantees noted the

significant concern of their patient populations in keeping records private in an environment

where everybody knows one another. According to grantees, in small close-knit

communities, close friends, neighbors, and family members often work at the local medical

facilities, leading to concern among patients that specific individuals may gain access to their

private medical records.

The grantees reported that they underestimated the complexity regarding privacy and

security policies and procedures needed. Addressing these issues took longer than they

planned for, and grantees spent significant time analyzing different breach scenarios.

Specifically, much discussion surrounded setting policies and procedures for authorization

(who is allowed to view a patient’s PHI) and auditing functionality (the ability to track who

has accessed a patient’s PHI). One grantee noted that they convened a privacy and security

workgroup to create the policies and procedures for their hospital within the context of

9

their State regulations. This grantee reported using the Connecting for Health Common

Framework44 documents as a starting point for creating policies and procedures for their

hospitals and facilities and recommended that others consider using these documents. In

addition, meeting HIPAA standards and keeping current with security regulations were cited

as challenges by the rural and safety net providers who have fewer technical and human

resources to address these requirements. This underscores the importance of the work of

Federal and industry efforts to continue to develop repositories of best practices and

guidance from experienced adopters of health IT in rural and underserved communities.

Additional solutions provided by the grantees included providing appropriate training to

staff on patient privacy. However, because grantees’ reported the concern by their patients

of abuse and breaches of their PHI, it may also be useful to develop consumer education

materials in order to increase patients’ awareness of HIE, how their health information will

be used and how it is protected.

Information Exchange Standards

To ensure that health care organizations can effectively exchange health information, systems

must be able to communicate with each other, professionals must have agreed on which data

are important to transmit, and the technical systems must be able to carry out these

exchanges of data. While not unique to safety net and rural providers, sharing and

exchanging data within a network is critical to maximizing the benefits of health IT and

improving the quality of care; grantees stated that disparate systems were a significant barrier

to sharing health information between partnering facilities. Because many of the projects

were initiated before the introduction of nationally recognized interoperability standards and

specifications for exchanging health data and standard-setting organizations, they often

encountered barriers to information exchange. In addition, grantees noted that in smaller or

resource-constrained communities, it was difficult for them to keep informed about the

national health IT agenda and industry guidance.

In the last few years, knowledge in the area of clinical standards and data exchange has

increased through efforts supported by the Federal Government, including the Health

10

Information Technology Standards Panel (HITSP), and the Certification Commission for

Healthcare Information Technology (CCHIT). Certification organizations like CCHIT

develop a comprehensive set of criteria for functionality, interoperability, and security that

make it easier for systems to interoperate. These efforts will continue to increase with the

funding available in ARRA: these funds will be directed towards qualified providers who are

“meaningful” users of EHRs. This demonstrates the need for a repository of this

information to serve as a resource for health IT implementers to find the most up-to-date

national guidance.

Collaboration of all stakeholders at the planning stages of projects was reported as critical to

the success of HIE between organizations. For example, one grantee convened a clinical

information steering committee that included representatives from the nine communities in

their system. This steering committee was charged with deciding what clinical data to be

exchanged and the specific standards to use. This steering committee was integral in

developing consensus and ensuring that the systems across the different organizations could

communicate with each other.

Organizational

Insufficient Informatics Expertise

Adopting and implementing health IT and HIE technology requires hiring staff with

specialized IT training, exacerbating the challenges rural and safety net provider

organizations already face in hiring and maintaining qualified staff. The availability of staff

with informatics and health informatics training in underserved and rural communities is

limited. One grantee described this as the “lack of and/or fragility of the bench,” meaning

that the pool of personnel resources in rural and underserved areas is not comparable to

that in urban areas or resource-rich health care organizations.

Several grantees reported the difficulty of hiring and retaining staff. Individuals are often

recruited and trained to serve as in-house IT experts, and once they have achieved a certain

amount of expertise, they are recruited and/or choose to work for a larger facility that can

offer higher salaries and greater benefits.

11

Even in organizations with knowledgeable IT staff, grantees from smaller organizations had

a limited number of IT staff, which contributed to delayed implementation and ongoing

maintenance issues. For example, one grantee described how his team implemented their

systems with only a handful of people who had to travel to multiple implementation sites in

two States. In addition, grantees noted that when they had a limited of number of IT staff,

these staff had many competing priorities because of their other responsibilities. With a

limited number of staff to support the whole IT functions for their entire hospital, the first

priority was to support normal hospital operations for patient care. This grantee noted,

“While interoperability was universally accepted as something to support, the hospital’s

ability to function comes first.”

Staff for Planning and Implementation

Limited involvement by IT staff during the planning and vendor selection phase of a health

IT implementation project can negatively impact the project’s success. One grantee noted

that in their enthusiasm to take something that worked in the private sector and apply it to

their safety net clinics, they underestimated the technology challenges as cited earlier. This

could have been mitigated with the input of IT staff or a technology consultant. In addition,

grantees stressed the importance of having qualified project management staff during both

planning and implementation phases. At the beginning of the project, a grantee project had a

physician leading the project and a nurse as the project manager. While their clinical input

was necessary, high-level project management expertise was also necessary to provide

support to the organizations and their providers as the system was implemented. While

hiring technology staff or a project manager may be prohibitive for underresourced

organizations, grantees suggested that private or government funding opportunities may be

one way to pay for this expertise in the short term.

Lack of Basic Computer Literacy

To maximize health IT and HIE capacity, both physicians and other health care staff need to

have some degree of computer literacy. Grantees noted that in some of their health care

organizations, some front office staff did not know how to use a computer and that a basic

12

level of computer training was necessary for staff to be comfortable using IT. Workforce

development and training, on both health IT and basic computer skills, are critical upfront

so that staff feel comfortable using IT.

Training

Although not unique to rural and underserved settings, another crucial component to the

success of the projects noted by the grantees was user training and outreach.34,45 However,

because of the computer literacy issue and limited informatics expertise mentioned

previously, grantees noted that training or development of a training program may take

longer or need to be tailored to address a lower level of familiarity with computer use.

Grantees suggested multifaceted approaches such as the “train-the-trainer” model, one-on-

one trainings with providers and staff, the development of pocket guides for providers and

including training materials on organizations’ Web sites.

One grantee emphasized the importance of training staff and providers on the integration

of technology into office workflow. They had only focused the training on how to use the

technology, in this case, a disease registry, but did not target training on how to integrate it

into the office workflow. The grantee suggested that the ideal training for providers would

include how to use the technology to maximize its benefit in encounters with patients.

Organizational Leadership

Introducing health technologies impacts the culture of an organization. According to

grantees, effective implementation necessitates a change in provider culture, attitudes, and

thought processes. A major lesson learned from the grantees was for leadership to be honest

and upfront with providers and other staff about the change in culture and workflow, “to be

as realistic as possible about the process and not try to sell anything.” They stressed that

these technologies are not simple tools that can be easily integrated into a new environment

and that providers and staff will have to change the way they work. Implementation leaders

must plan for social and cultural changes that will accompany the introduction of new

technologies.

13

Grantees also stressed the importance of consistent and informed organizational leadership,

which is consistent with existing literature.46 Staff turnover at the leadership level was

identified as a huge challenge by the grantees working in rural and underserved areas, and

hiring new staff and getting them up to speed delayed the planned implementations. The

time needed to rebuild the momentum, vision, and interest among key players was a

challenge. Given the limited resources and the time and effort it takes to secure buy in to the

vision and implementation plan, losing a project champion can slow down a project.

Cultivating new relationships and gaining buy in has to be repeated, which takes staff time

away from other priorities, and the outcome is not always positive for the project. One

grantee noted that when a new CEO or other high-level leadership comes on board, there

are many local issues that are on their priority list to be managed. This can impact the

leaders’ willingness to engage at a regional level and invest a large sum of money into a

legacy project. In addition, other key players often lose interest once momentum slows down

as new leadership comes up to speed. While the importance of organizational leadership is

central to the success of health IT and HIE implementations in all settings, it is exacerbated

in rural or underserved settings where resources are more limited and the time and cost of

recruitment of leadership personnel is high.

Staff and Physician Buy In

It has been noted that when providers recognize the added value of a health IT tool, they are

far more likely to adopt that technology than when there is no apparent added value. These

grantees were no different, reporting staff and physician resistance to learning new systems

and stressing the need for making the business case for the technology for every provider.

Consistent with existing literature, the grantees stressed the importance of physician

champions for technology or other types of practice change. For example, “we need a

physician champion who can speak to why this can work and how it can fit into the eight

minute visit.” As previously noted, grantees reported the importance of staff and provider

education of the value of the technologies to their patients and to their jobs.

14

Financial

Funding

A significant barrier cited by the majority of grantees was the financial resources required to

fund their planning and implementation costs. Financial barriers are particularly pronounced

for rural physicians because they typically practice in single-specialty, solo, or small groups

which traditionally lack the financial resources needed for health IT implementation. In

addition, most safety net providers are supported by government funding and have limited

financial resources.

While grantees were provided with supplemental funding from AHRQ, start-up costs were

significant and the grantees had to rely on other sources of funding. In addition to receiving

grants from Federal and State agencies as well as other external organizations, facilities often

rely on internal funding to begin, complete, or expand health IT implementation. Health

care facilities operating in rural and underserved areas often have limited profit margins and

therefore limited funding available to extend beyond direct patient care expenses. In

addition, capital expenses for health IT were in “competition” for other equipment such as

computed tomography (CT) scanners. As a result, health IT implementation projects can

often be difficult to initiate and/or take a long time to roll-out because consistent funding

can be difficult to secure. Grantees noted that without the availability of external funding, it

would be difficult or near impossible for rural and underserved facilities to implement basic

health IT. Specifically, one grantee noted that without the AHRQ funding, their project

would not have been possible.

While grantees continue to rely on grants from Federal and State agencies and other

nonprofit agencies, some of their solutions to overcome their financial disadvantage include

pooling resources from participating facilities and approaching employers and other

stakeholders who have a vested interested in improving the overall health of their

community. Another grantee reported working directly with senior leadership to educate

them on the benefits of the health IT to ensure their projects are considered in budget plans.

15

The absence of large employers can be a key component impacting the sustainability model

for projects implementing an HIE. According to one grantee, it can be difficult to get buy in

from large employers in their area, because in rural communities the number of large

employers is limited and often includes the government, hospitals, and State prisons. In

addition, the smaller employers tend not to offer health insurance and therefore are less

likely to engage in HIE-related activities because they do not have as much financially at

stake as employers that provide insurance coverage. To get buy in from employers, grantees

recommended a variety of solutions: engaging employers before the implementation project

begins to ensure their interests are included; creating a business case for employers to ensure

their commitment over the long term; conducting presentations with large and small

employers to demonstrate the benefit that population health management can have in their

community, workforce, and financial strategy; holding live demonstrations once the project

begins so employers can visualize the technology and see the progress; and partnering with

any large, private health insurers who cover the area’s population.

Funding in the ARRA presents an unprecedented opportunity to increase health IT adoption

in the United States. The Health Information Technology for Economic and Clinical Health

Act within the ARRA appropriates $36 billion to be used over the next 6 years to encourage

health IT and HIE adoption. This includes grants for planning and implementation of

health IT, EHR loan funds, and Medicare and Medicaid payments to incentivize providers to

adopt. In addition, within the ARRA’s broader health funding program, there is $1.5 billion

in designated funds, to be disbursed through HRSA, for federally qualified health centers to

improve their infrastructure. These funds can be used for construction, renovation,

equipment, and acquisition of health IT.

16

AHRQ has funded a diverse set of projects to implement health IT and HIE in rural and

underserved areas. The open forum discussion with grantees serving rural and undeserved

communities provided rich detail about their experiences planning and implementing HIE

and health information technologies, including major challenges, solutions, and lessons

learned. The majority of the identified technical, policy, organizational, and financial

challenges mirror much of what has previously been described, demonstrating the need for

continued attention and a coordinated effort to support those new to health IT

implementation. However, as more organizations serving rural and underserved

communities implement health IT, it is imperative that these support mechanisms are in

place as these organizations have even fewer financial and personnel resources and thus less

room for failure.

From our discussions with the grantees, their primary challenge continues to be financial

costs to plan and implement health IT, even with funding from AHRQ. The ARRA includes

a variety of provisions that will impact the financing of health IT for rural and safety net

health providers. Beginning in 2011, providers enrolled in the Medicare program who

implement and report meaningful use of EHRs can receive initial incentive payments up to

$18,000 and total payments up to $44,000. Providers in rural health professional shortage

areas will be eligible for a 10-percent increase on these payment amounts. In addition, there

are payments to State Medicaid plans that implement programs to encourage the adoption

and use of certified EHRs. The programs may make payments to providers, up to $63,750

toward adoption, implementation, upgrades, maintenance, and operation of certified EHRs.

Providers must choose between health IT funding through Medicare or Medicaid; however,

acute care hospitals are eligible for both the Medicare and Medicaid incentive programs.

These incentive programs present opportunities for rural and safety net providers to recoup

some of the costs of their implementations, especially since they serve a large Medicare and

Medicaid population.

An additional challenge cited by the rural grantees was the limited numbers of available

individuals with IT or informatics expertise in their communities, revealing the need for

Conclusion

17

significant workforce training. Significant funding opportunities also are included in the

ARRA for health IT training programs to increase the number of workers with this

expertise. These include grants to academic institutions to expand medical informatics

training programs and to integrate information technology into the curriculum of their

clinical programs.

Finally, grantees continue to struggle with many issues related to planning and

implementation, including vendor selection, privacy and confidentiality policies, and

selection and use of standards. This underscores the importance of the NRC to continue to

be a repository for best practices and lessons learned as well as a technical assistance

provider.

18

1. Agency for Healthcare Research and Quality. AHRQ Health IT Program Brief. Available at:

http://www.ahrq.gov/research/hitfact.htm. Accessed June 19, 2009.

2. Department of Health and Human Services (DHHS. Transforming Healthcare Quality through

Information Technology Information THQIT) – Implementation Grants. RFA Number: RFA-HS-04-

011. Release Date: November 20, 2003. Available at: http://grants.nih.gov/grants/guide/rfa-files/RFA-

HS-04-011.html. Accessed July 8, 2009.

3. Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups.

Health Serv Res 1995 Apr;30(1 Pt 2):253-73. Review.

4. Eberhardt M, Ingram D, Makuc D. Urban and rural health chartbook. Health, United States, 2001.

Hyattsville, Maryland: National Center for Health Statistics, 2001.

5. Agency for Healthcare Research and Quality. 2005 National Healthcare Disparities Report. Rockville,

MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality;

December 2005. AHRQ Pub. No. 06-0017.

6. American College of Physicians. Rural Primary Care. Ann Intern Med 1995;122(5): 380-90.

7. Schur L, Franco S. Access to health care. In: Ricketts T, ed. Rural health in the United States. New York:

Oxford University Press; 1999. p. 25-37.

8. Gaskin DJ, Arbelaez JJ, Brown JR, et al. Examining racial and ethnic disparities in site of usual source of

care. J Natl Med Assoc 2007 Jan;99(1):22-30.

9. Mead H, Cartwright-Smith L, Jones K, et al. Racial and ethnic disparities in U.S. health care: a chartbook.

New York: The Commonwealth Fund; March 2008. Commonwealth Pub. No. 1111.

10. Agency for Healthcare Research and Quality. 2004 National Healthcare Disparities Report. Rockville,

MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality;

December 2004. AHRQ Pub. No. 05-0014.

11. Hess DC, Wang S, Gross H, et al. Telestroke: extending stroke expertise into underserved areas. Lancet

Neurol 2006;5(3):275-8.

12. Levine SR, Gorman M. Telestroke: the application of telemedicine for stroke. Stroke 1999;30(2):464-9.

13. Bodenheimer TM, Shafiri C. Helping patients manage their chronic conditions. California Healthcare

Foundation; 2005. Available at: http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=111768.

Accessed June 19, 2009.

14. Centers for Disease Control and Prevention. State programs in action. Exemplary work to prevent

chronic disease and promote health. Atlanta: U.S. Department of Health and Human Services; 2003.

Available at http://www.cdc.gov/nccdphp/publications/Exemplary. Accessed June 19, 2009.

References

19

15. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau

of Primary Health Care. Health Centers: America’s Primary Care Safety Net, Reflections on Success,

2002-2007. Rockville, MD. June 2008.

16. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality,

efficiency, and costs of medical care. Ann Intern Med 2006; 144:742-52.

17. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error

prevention. J Am Med Inform Assoc 1999;6(4):313-21.

18. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision

support systems on medication safety: a systematic review. Arch Intern Med 2003;163(12):1409-16.

19. Teich JM, Merchia PR, Schmiz JL, et al. Effects of computerized physician order entry on prescribing

practices. Arch Intern Med 2000 Oct 9;160(18):2741-7.

20. Gandhi TK, Weingart SN, Seger AC, et al. Outpatient prescribing errors and the impact of computerized

prescribing. J Gen Intern Med 2005;20(9):837-41.

21. Dexter PR, Perkins SM, Maharry KS, et al. Inpatient computer-based standing orders vs physician

reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA

2004;292(19):2366-71.

22. Chertow GM, Lee J, Kuperman GJ, et al. Guided medication dosing for inpatients with renal

insufficiency. JAMA 2001;12;286(22):2839-44.

23. Overhage JM, Tierney WM, Zhou XH, McDonald CJ.. A randomized trial of "corollary orders" to

prevent errors of omission. J Am Med Inform Assoc 1997;4(5):364-75.

24. Peterson JF, Kuperman GJ, Shek C, et al. Guided prescription of psychotropic medications for geriatric

inpatients. Arch Intern Med 2005;165(7):802-7.

25. Dexter PR, Perkins S, Overhage JM, et al. A computerized reminder system to increase the use of

preventive care for hospitalized patients. N Engl J Med 2001; 345(13):965-70.

26. Taylor R, Manzo J, Sinnett M. Quantifying value for physician order-entry systems: a balance of cost and

quality. Health Finance Manage 2002;56(7):44-8.

27. Institute of Medicine. Quality through collaboration. The future of rural health. Washington DC:

National Academies Press; 2005.

28. Hersh WR, Wallace JA, Patterson PK, et al. Telemedicine for the Medicare population: pediatric,

obstetric, and clinician-indirect home interventions. Evid Rep Technol Assess (Summ). 2001;(24 Suppl):1-

32.

29. Ellis DG, Mayrose J, Jehle DV, et al. A telemedicine model for emergency care in a short-term

correctional facility. Telemed J E Health 2001;7(2):87-92.

20

30. Wakefield BJ, Buresh KA, Flanagan JR, Kienzle MG. Interactive video specialty consultations in long-

term care. J Am Geriatr Soc 2004;52(5):789-93.

31. Jha AK, Desroches CM, Campbell EG, et al. Use of Electronic Health Records in U.S. Hospitals. N Engl

J Med 2009 Apr 16;360(16):1628-38. Epub 2009 Mar 25.

32. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care--a national

survey of physicians. N Engl J Med 2008;359(1):50-60.

33. Annual HIMSS leadership survey: Healthcare CIO survey final report.

http://www.himss.org/content/files/surveyresults. Accessed June 19, 2009.

34. Ash JS, Bates DW. Factors and forces affecting EHR system adoption: report of a 2004 ACMI

discussion. J Am Med Inform Assoc 2005;12(1):8-12.

35. eHealth Initiative. 2008. Fifth annual survey of health information exchange at the state and local levels:

overview of 2008 findings. Available at:

http://www.ehealthinitiative.org/assets/Documents/eHealthInitiativeResults2008SurveyonHealthInform

ationExchangeSeptember2008Final091108.pdf. Accessed June 19, 2009.

36. Adler-Milstein J, Bates DW, Jha AK. U.S. Regional health information organizations: progress and

challenges. Health Aff (Millwood). 2009 Mar-Apr;28(2):483-92.

37. State Level Health Information Exchange Consensus Project. 2008. Roles in ensuring governance and

advancing interoperability. Available at: http://www.slhie.org/Docs/FinalReportPart1.8.pdf. Accessed

June 19, 2009.

38. National Governors Association Center for Best Practices. Report to the state alliance for e-Health:

Public governance models for a sustainable health information exchange industry. Available at:

http://www.nga.org/Files/pdf/0902EHEALTHHIEREPORT.PDF. Accessed June 19, 2009.

39. The Agency for Healthcare Research and Quality. 2006. Evolution of State Health Information

Exchange: A Study of Vision, Strategy and Progress. Available at:

http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_130379_0_0_18/AHRQ%20HIE%20St

ate%20Based%20Final%20Report.pdf. Accessed June 19, 2009.

40. Turisco F, Metzger J. Rural health care delivery: Connecting communities through technology. California

Healthcare Foundation. November 2002.

41. Murchinson JV, Apodaca A, Sison CE, et al. For the record: EHR adoption in the safety net. California

HealthCare Foundation. February 2009.

42. Pew Internet & American Life Project. Home Broadband Adoption 2009. June 2009.

43. Bahensky JA, Jaana M, Ward MM. Health care information technology in rural America: electronic

medical record adoption status in meeting the national agenda. J Rural Health 2008 Spring;24(2):101-5.

44. Connecting for Health Common Framework. Available at:

http://www.connectingforhealth.org/commonframework/. Accessed June 19, 2009.

21

45. Zandieh SO, Yoon-Flannery K, Kuperman GJ, et al. Challenges to EHR implementation in electronic

versus paper-based office practices. J Gen Intern Med 2008;23(6):755-61. Epub 2008 Mar 28.

46. Bahensky JA, Moreau B, Frieden R, Ward MM. Critical access hospital informatics: how two rural Iowa

hospitals overcame challenges to achieve IT excellence. J Healthc Inf Manag 2008 Spring;22(2):16-22.

22

TrAnSFOrMing HeAlTHCAre QuAliTy THrOugH inFOrMATiOn TeCHnOlOgy

OPen FOruM PArTiCiPAnTS

*Grantee did not participate in the open forum but provided input during a followup discussion.

Project Principal Project Short Project Population

name investigator representatives Description location Served

Accessing Kiki Nocella, Kiki Nocella, Goal: to have the ability to do California Rural

the Cutting MHA, PhD MHA, PhD population-wide prevention

Edge- nocella@usc.edu nocella@usc.edu population methods,

Implementing specifically immunization.

Technology Jami Young Currently, 100 percent of

to Transform jamiyoung@ PCPs are participating with

Quality in tvhd.org EHRs. Implements and

SE Kern evaluates an Integrated

County Technology Association

("ITA") that addresses these

three key aims:

1. Build infrastructure: Create

a culture, organization, and

mechanisms that promote

safe, high-quality care.

2. Enhance the health

professions workforce

through education and

organization.

3. Enhance quality care using

health IT, focusing on

diabetic care as a model.

Appendix

23

Project Principal Project Short Project Population

name investigator representatives Description location Served

*Connecting Polly Bentley Polly Bentley Appalachian Regional Kentucky Rural

Healthcare pbentley@arh.org pbentley@arh.org Healthcare, Inc., is an

in Central integrated rural health care

Appalachia delivery system serving

approximately 20 counties

throughout eastern Kentucky

and southern West Virginia.

With this proposal, the various

facilities that make up the

ARM system will launch the

implementation of a major

component of its clinical

information initiative. The

implementation of the initial

stages of electronic medical

records will increase the

timeliness and accuracy of

care provided to patients,

improve workflow throughout

the system and across the

continuum of care, and

ultimately, improve the overall

quality of care provided to

patients. Funding requested

with this proposal will provide

essential hardware components

to initiate this kick-off, training

for project core team members

and hospital medical records

staff, and the personnel costs

associated with the adaptation

of the electronic medical

records system to

accommodate ARH's needs

and the standardization of

forms to complement

the system.

24

Project

name

Principal

investigator r

Project

epresentatives

Short

Description

Project

location

Population

Served

El Dorado

County

Safety Net

Technology

Project

(ACCESS)

Greg Bergner, M.D.

bergner@

sbcglobal.net

Sandra Dunn,

sandradunn@

mindspring.com

The Project is an ambitious

effort to affect the patient

safety/quality of care

delivered to uninsured/

underinsured children and

employed adults and families

in El Dorado County. The

Network consists of the

major providers of health

care services to the safety

net population (indigent,

uninsured, underinsured)

and includes local hospitals,

community clinics, the

County Mental Health,

Public Health, and Human

Services Depts., the Office

of Education, and several

non-profits serving this

population.

The Project will integrate the

Network's "Access Product,”

a three-pronged approach to

providing:

1. Outreach and enrollment

for children eligible for

public insurance

2. Access for those children

not eligible for public

insurance, up to 300

percent of the poverty level

3. Access to health care to

those families employed by

local small businesses

unable to provide coverage

for their workers.

El Dorado

County,

California

170,000

patients, 40%

of which

are below

the Federal

poverty

level.

25

Project Principal Project Short Project Population

name investigator representatives Description location Served

Health Nancy Shank Nancy Shank Implements regional health Nebraska Rural health

Information nshank@ nshank@ information exchange (HIEs) Panhandle clinics

Exchange: nebraska.edu nebraska.edu within an established Federal

A Frontier collaborative of rural hospitals, medical

Model Elizabeth Wilborn

ewillborn@

nebraska.edu

clinics, public health providers,

behavioral health providers,

and others across a 14,000

square mile remote area. The

intended outcomes are to

create electronic medical

records that are integrated

with other functional systems

in all Critical Access Hospitals

and Rural Health Clinics; HIE

systems that provide current

information, from all hospitals

and rural health clinics, at the

point of care; and an opera-

tional entity and incorporated

RHIO to provide the sustain-

able infrastructure necessary

to support regional HIE and

common developments in the

electronic health records.

centers

26

Project Principal Project Short Project Population

name investigator representatives Description location Served

Holomua Christine Sakuda Christine Sakuda Increases patient safety, quality Hawaii Pacific Island

Project csakuda@ csakuda@ and continuity of care during pop. (do not

Improving hawaiipca.net hawaiipca.net transitional care for vulnerable speak

Transitional populations in Hawaii through English)

Care in Beverly Chin improving the flow of

Hawaii bchin@

hawaiipca.net

information between patients/

families, community health

centers and hospitals using

health IT. The project aims to:

increase accuracy and

timeliness of shared patient

information during

transitional care between

primary care and tertiary care

facilities; reduce incidence of

medical errors that may occur

due to linguistic and/or

cultural barriers between

patients and medical providers;

reduce occurrences of

duplicated diagnostic

procedures performed on

patients due to lack of

communication between

primary care and tertiary care

facilities; increase participation

and involvement in decision

making by patients or family

on health related matters; and

determine mechanisms by

which information resources,

information systems, and

other IT initiatives and/or

networks in Hawaii can best

support the Holomua Project.

27

Project Principal Project Short Project Population

name investigator representatives Description location Served

Implement- Mark Jones Mark Jones Implement a HIPAA-compliant Oklahoma Underserved,

ation of markjhealth@ markjhealth@ approach to the selection of Tribal

Health yahoo.com yahoo.com a common set of patient population

Collaboration health data that can be

in Joanna Walkingstick transferred electronically

Oklahoma joannawalkingstick@

smrtnet.org

between community health

care providers, thereby

resulting in an array of positive

operational and secondary

outcomes to community health

networks. The primary goals

are: Implementation of an

Electronic Health Information

System among 7 agencies;

Implementation of a Web-

based 24/7 Information and

Referral Service that includes

back-up 24/7 telephone

service; and Implementation

of a Community-wide science-

based prevention strategy that

is supported by community-

based health IT data systems.

Integris Charles Bryant Cynthia Scheideman- Project tries to answer the Oklahoma Rural and

Telewound Ehsdrbryant@ Miller question: “Can you reduce a metro

Care sbcglobal.net clsmiller@ patients ‘healing time’ by counties,

Network sbcglobal.net using health IT?”

Demonstrates and evaluates

the clinical effectiveness and

cost-savings of utilizing

telehealth technology to

reduce the days to healing for

chronic wounds by improving

access to caregivers, point of

care processes, and

dissemination of best practice

information.

predominantly

with patients

that have

wounds that

are not

healing

28

Project Principal Project Short Project Population

name investigator representatives Description location Served

Metro DC Thomas Lewis Thomas Lewis Address the health care needs Metro DC Low-SES,

Health Tom_Lewis@ Tom_Lewis@ of low-income, uninsured uninsured,

Information Primarycare Primarycare individuals and families using urban

Exchange coalition coalition a secure, comprehensive, community-

(MeDHIX) virtual health record for

medically underserved patients

that are longitudinal, portable,

and accessible; spanning all

forms of encounters across

diverse health care settings.

The principal forward-looking

objective is to implement the

health information technology

infrastructure necessary to

support a single, shared

electronic medical record

application that, in turn, will

promote the community-wide

exchange of patient

information for clinical decision

support; research; and disease

management on behalf of

low-income, uninsured people.

based health

care providers

Project Sanjeev Arora Sanjeev Arora Connects urban medical center Albuquerque, Rural

ECHO Sarora@Salud. Sarora@Salud. disease experts with rural New Mexico

Extension Unm.edu Unm.edu general practitioners and

for community health

Community John Brown representatives over a

Healthcare telehealth network to effectively

Outcomes treat patients with chronic,

common and complex diseases

who do not have direct access

to specialty health care providers.

Project Peggy Esch Dinni McColm Creates a community-wide Southwest Rural

Infocare Plesch@citizens

memorial.com

denni.mccolm@

citizensmemorial.com

electronic medical record with

integrated clinical decision

support that is available across

the continuum of care

including a rural hospital, a

home health agency, 14

physician clinics, and 5

long-term care facilities.

Missouri

29

Project Principal Project Short Project Population

name investigator representatives Description location Served

Regional

Approach

for THQIT

in Rural

Settings

Francis Richards

Frichards@

geisinger.edu

Jim Younkin

jryounkin@

geisinger.edu

James Walker

Jmwalker@

geisinger.edu

This project is centered

around three main objectives:

improving access to existing

clinical information by rural

health care providers; improving

communications between

primary care providers and

specialists; and laying the

foundation for a regional

network that supports

information sharing among

rural hospitals and providers

and creates an environment

that encourages the adoption

of health information

technology.

Central

Pennsylvania

Rural

Rural Iowa Donald Crandall Jane Brokel Implement a comprehensive, North- Elderly

Redesign of Crandald@Trinity- brokelj@trinity- integrated, EHR system using central population

Care Health.org health.org data standards, with Iowa; (14 counties)

Delivery computerized provider order worked with More than

with EHR entry and clinical decision Trinity 40% of the

Functions support tools, in several diverse,

rural, northern Iowa health

care settings (hospital inpatient

units, ambulatory care, primary

care and specialty clinics, home

health, and hospice care) and

to evaluate the effect of this

electronic health record system

on patient care and

organizational culture.

Health

out of

Michigan

population

in the area

serviced are

over 80

years of age

30

Project

name

Principal

investigator r

Project

epresentatives

Short

Description

Project

location

Population

Served

*Santa Cruz

County

Diabetes

Mellitus

Registry

Eleanor Littman

ellie@hpscc.org

Eleanor Littman

ellie@hpscc.org

Dorian Seamster

dorian@hipscc.org

The Santa Cruz County

Diabetes Mellitus Registry

project builds on a history of

productive collaboration

among the County's public,

private, and not-for-profit

health sectors. Two physician

organizations, the County's

Medicaid HMO, the health

department, a local community

college, and a local

philanthropy form the project

team. The clinical entities have

agreed to share encounter/

claim, laboratory, and pharmacy

data to populate a county-

wide diabetes registry. The

registry software was

developed by one of the

physician groups, whose

Medical Director will serve

as the project's principal

investigator. The existing

registry is Web-based and

interactive, giving physicians

and their colleagues many

options for improving the

standard of diabetes care

provided to patients. Prompts

can remind physicians and

medical assistants about

needed tests at the point of

care; the registry also can

generate lists of patients

overdue for exams or tests

so that medical office staff

can accelerate the

appointment process.

Santa Cruz,

CA

Include

Safety Net

Clinics

AHRQ Publication No. 10-0047-EFFebruary 2010